Tag Archives: gutka

New claims about burden of disease from smokeless tobacco are utter junk (the short version)

by Carl V Phillips

There have been a spate of claims recently, stemming from this junk science paper (“Global burden of disease due to smokeless tobacco consumption in adults: analysis of data from 113 countries” by Kamran Siddiqi, Sarwat Shah, Syed Muslim Abbas, Aishwarya Vidyasagaran, Mohammed Jawad, Omara Dogar and Aziz Sheikh) that there is some huge health burden from smokeless tobacco. This piece of utter crap — bad even by the standards of tobacco control “research” — deserves a detailed point-by-point critique, but it is just so bad that I cannot stand to do it right now. So I am going to provide the short version. Continue reading

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By the numbers, harm reduction is mostly about tobacco (including in India)

by Carl V Phillips

Harm Reduction International (HRI; formerly the International Harm Reduction Association, IHRA) just released a long report with the bold title, “The Global State of Harm Reduction, 2014”. Before you bother to look at it, though, I will point out that despite the broad title, it is only about heroin use and other injection drug use, and it is almost all about process (whether particular helpful government programs exist) rather than outcomes. Sadly, for this once broad-minded organization, which once also focused on harm reduction for much more common behaviors, they seem to have collapsed down to a narrow niche. They used to include in their purview sexual behavior, drug use more generally, and even let alcohol in the door. (They balked at including THR, however, because they were scared to challenge the powerful anti-tobacco lobby. That really says something, given that they are willing to challenge dictators who imprison people for advocating on behalf of injection drug users.)

Not that there is anything wrong with the narrow niche they have retreated to. The people in it are at particularly high risk, and are particularly badly treated. HRI should just stop speaking of it as if it were all of harm reduction, which it obviously is not. Even if we exclude from the term things like seat belts, and stick to the sense of “helping people who choose to engage in behaviors that there are attacked by governments and are otherwise the target of organized opprobrium campaigns” all of injection drug use is still a tiny niche. According to their numbers, they are talking about 10 to 20 million people worldwide. Compare that to over a billion smokers.

In fairness, injection drug users often lose many decades of potential life, as well as much of their potential productivity and ability to function in society. These losses are substantially due to HIV exposure and criminalization, and therefore could be dramatically reduced through harm reduction measures (providing clean needles, eliminating criminalization, offering lower-risk alternatives, etc.). This contrasts with smoking, where smokers lose only a few years of potential life, no productivity, and almost no ability to function. However, to the extent that smoking cause a loss of ability to function (apart from the health effects), it is entirely caused by the quasi-criminalization (punitive taxes that lower people’s wealth, place restrictions, etc.). And, of course, the health risks exist — more or less entirely — because people do not have access to satisfying low-risk alternatives, again thanks to organized campaigns by governments and others.

The situations are remarkably similar, they just differ in which number — the cost to the individual or the number of individuals suffering the costs — is bigger. When you multiply the losses by the population, smoking dwarfs injection drug use.

The HRI report emphasizes Asia, where problems from heroin are worst for various obvious reasons. Also in my inbox today was a call-for-papers from Harm Reduction Journal, for a special issue on harm reduction in Asia. The blurb about it is, unfortunately, restricted to HIV and injection drug use (again, not that those do not deserve attention, but they already get a lot of attention compared to tobacco-related harm reduction issues). However, I did inquire earlier about whether tobacco-related harm reduction articles would be welcome (I am an associate editor of the journal, so had advanced notice), and was told yes. [Update 05mar15: That yes became a no. They do not want my paper about tobacco harm reduction in Asia after all. Again, there is nothing wrong with a special issue specifically about IDU harm reduction in Asia — it should just not be called “harm reduction in Asia” without further qualification.]

There is a paper that I have mostly already written in various forms that I would like to submit. [Update, continued: I still want to write the paper, just not for that issue. And I have found a potential coauthor. But others are still welcome to jump in.] Mostly, but with one gap I cannot fill — and that is why I mention this here and where you come in, dear readers.

Oral dip products used by hundreds of millions of people in South Asia appear to be extremely harmful. If you believe the epidemiology that has been reported (which is pretty sketchy and biased, but is what we have), they cause life-threatening and debilitating diseases at a substantial fraction of the rate that smoking does, and which tend to occur much younger. The government response currently focuses on criminalization. If it were possible to substitute smokeless tobacco for these products — not a perfect substitute, since it is not as psychoactively potent, but similar enough to possibly work — the per capita reduction in harm would be similar to the reduction from substituting it for smoking. And, of course, it would allow people with very tough and sparse lives to continue to do a version of something they like.

There are two major barriers to this. India and other governments, driven by anti-tobacco crusaders at WHO, inaccurately designate the products that are used as “smokeless tobacco”. The products are primarily other substances, however, with tobacco sometimes included as a tertiary ingredient. The harms obviously do not come from the tobacco, since these products apparently cause a lot of harm, while smokeless tobacco does not. But it is hard to convince people to substitute smokeless tobacco for a product they are already being told is smokeless tobacco. WHO is basically sacrificing poor third-world users of these products in order to pursue their campaign of vilifying actual smokeless tobacco use in the West.

The other issue is whether it can be made affordable, and that is the one I simply do not know the answer to. The products currently used cost the equivalent of only a couple of cents per dose, which is about all that most of those who use them can afford. Using Western brand products, at a cost that is more than an order of magnitude greater, is out of the question for most of the target population. For this to work, there would need to be a domestic industry that could make product at prices that are locally affordable. India is a major tobacco leaf producer, so the raw ingredient is there, but I do not know if a local production process could be made cheap enough. Anyone out there have any idea, or know someone who does, either inside or outside of industry, and want to either be a coauthor or give me data?

Obviously this would just be a thought experiment about what could theoretically be done. But no one is likely to turn it into a political cause (or entrepreneurial business plan [Update, continued: My potential coauthor informed, very politely, that I was being rather ivory tower with this observation. He is already engaging in exactly that entrepreneurship. I should have had more faith in the market!]) without the thought experiment. And it matters. The number of people this novel form of THR could help is within an order of magnitude of the number of smokers who can benefit from THR.

The biggest victims of WHO’s anti-harm-reduction efforts are in India

by Carl V Phillips

Tobacco harm reduction supporters and vapers have been (rightly) incensed by the World Health Organization’s (aka The Organization WHO Must Not Be Named) recent disinformation about e-cigarettes and proposed policies that would inappropriately restrict them. But there is good news for >99% of those of you speaking up about this: You live in a country where an extremist cabal at the WHO has limited influence. Not so for the unfortunate citizens of India and neighboring countries. Continue reading

Anti-THR liar of the year #3: The World Health Organization (and a Dishonorable Mention for the Continuumistas)

Continuing the countdown of 2013’s top anti-THR liars, we should not forget that THR is not just about e-cigarettes or people who are rich enough to afford them.  Smokeless tobacco is still the leading method for THR in terms of number of users and proven efficacy and effectiveness.  The World Health [sic] Organization (WHO) — including its International Agency for Research on Cancer (IARC) and Framework Convention on Tobacco Control (FCTC) units — has long been one of the leading liars about smokeless tobacco.  While their lying is not as aggressive as it once was (and thus they rank only third this year in spite of their enormous reach), it is still going strong.

This matters because the lies have some influence on the knowledge of people in rich countries — for example, IARC played an important role in tricking people into believing that snus causes cancer to a measurable degree despite the lack of any such evidence.  But it matters much more because many poor countries simply take their public health marching orders from the WHO.

Among such countries are India and its neighbors, where there is great potential for tobacco harm reduction of a different kind.  Millions of people in South Asia use the dip product gutka and others that are similar to it, and these appear to create so much risk of cancer and other oral diseases that their health impact may be up with smoking.  The potential harm reduction that would come from persuading people to switch to smokeless tobacco — an obvious substitute that is low-risk and can be affordably manufactured locally — is enormous.  The number of users of those products is in the order of a tenth the number of smokers in the world.  Enter the WHO, which erroneously claims that these products are smokeless tobacco (tobacco is one of the ingredients, but clearly not the one that is causing the large health impacts).

Not only does this basically guarantee that there will be no attempt at harm reduction in South Asia, but it then carries back to the rest of the world that is tricked into believing that smokeless tobacco causes risks similar to gutka.  This leads to harmful lies like this, where the claim is that smokeless tobacco is 17% as risky as smoking (the absurdity of making a claim that precise, even beyond the fact that it is wrong by an order of magnitude, is a topic for another day).  This tends to discourage smokers from switching to this proven low-risk alternative.

The WHO has not spared e-cigarettes from its anti-THR lies, though they are a relatively minor player there, in contrast with being singularly devastating in their history of lies about smokeless tobacco.  Hat tip to Clive Bates for compiling this list of tweets, which speaks for itself:

WHO lies about e-cigarettes

Dishonorable Mention:  the Continuumistas

Another tribe of semi-liars are the “continuumistas” (not the best neologism meme ever, but useful), those who persist in mistakenly claiming that there is a “continuum of risk” among tobacco products.  This relates closely to the above points about different products and comparative risks.  The “continuum” claim may have been made more times in 2013 than in all previous history.  However, we did not rank the continuumistas on this list because it not really the same as the other lies:  While this is often an anti-THR tactic, in many cases it is not intentional and, indeed, many pro-THR commentators make this error.  Still, it is important and harmful, so deserves a mention.

Some of us have been pointing out for years why this claim is wrong and harmful.  For more details, read this, but to summarize the key point:  Claiming there is a continuum of risk suggests that tobacco products are spread out across the spectrum from zero up to the risk of cigarettes.  If someone believes that is true, they try to fill in the space, and so they dramatically elevate the claimed risk from some products, as with that 17%.  The reality is that there are basically just two relevant points: cigarettes and “about zero”.  The latter includes smokeless tobacco, NRT, and e-cigarettes, as well as abstinence.  The risks from all of these are so close that we cannot measure any differences, and so if you were to graph these risks versus smoking, they would all occupy the same dot on the graph.

So what explains the continuumistas in light of that distribution being about as far from continuous as is possible?  Some of them are out-and-out anti-THR liars, who are trying to suggest that no one should use the effective and satisfying THR products — or even that such products should be banned — because there is something else that is even lower risk.  Historically it was smokeless tobacco that was inaccurately moved into the empty zone between cigarettes and zero, but increasingly it has been e-cigarettes.  In many cases this involves absurd made-up numbers (e.g., “smokeless tobacco poses 10% the risk of smoking” or “why reduce your risk by half by switching to vaping when you can eliminate it entirely”), though sometimes it is similarly misleading graphical representations.

The claim is also actively perpetuated by industry in an attempt to muddy the waters and distract from the simple message: “combustion = bad for you; all else that currently exists and matters in the marketplace = no measurable risk”.  (In fairness, industry is trying to develop some smoking-like products that might occupy that middle space, with much less risk than smoking but more appeal to many smokers who do not like the smoke-free options; still, this does not make the continuum message accurate.)  Regulators also tend to like the notion because they like complication, and it keeps them from having to admit that the best choices — which they are often not making — are quite obvious and simple.  Finally, many THR supporters who are trying to position themselves as “moderates” seem to like the concept because it lets them avoid stating the highly confrontational implications of the simple message (“we can all agree there is a continuum of risk, right?… aah, good, so we are all on the same page”).

But whether used as intentional manipulation, a highly-toxic compromise between the truth and politics, or mere thoughtless repetition, the continuumista message is harmful for THR as a classic case of “the perfect is the enemy of the good”.  By suggesting that abstinence is perfect and thus “merely” good alternatives are too far away from it, many people are discouraged from taking the good options that are so close to perfect that the difference does not matter.

WHO lying about smokeless tobacco again

by Carl V Phillips

For those who may not know, the World Health Organization is one of the worst anti-THR liars in the world.  The prominence of their role as liars has fallen behind some other players in the Anglophone discourse recently, perhaps because their FCTC process has been largely eclipsed by the FDA, MHRA, and EU processes, because the WHO are slow and plodding so have not managed to become very actively anti-ecig yet.  But they, including their propaganda-science unit, the International Agency for Research on Cancer (IARC), are still trying to keep people smoking.

In this press release (h/t Clive Bates), WHO claims smokeless tobacco causes a huge number of cases of oral cancer and creates a huge health and financial toll in India and other countries in that region.  The announcement includes the news that the governments in that region are embarking on a goal (note: I intentionally did not say “plan”) to reduce use by 30%.  For those who do not know, this really means that WHO set that goal — in this region and in many other poor countries, insult is added to poverty by having a bunch of rich operatives in Geneva act as puppet masters for the national health authorities.

The lie here is that people in that region don’t use smokeless tobacco.  The cheap and ubiquitous causal drugs (filling the same niche that coffee, tea, tobacco, coca, etc. do in other cultures) used by millions of people in that region consist of several ingredients.  Sometimes tobacco is one of them, though sometimes not.  When it is included, it is typically the third ingredient down the list.

It is true that these products cause lots of oral diseases.  While the formal research on this is terrible quality and barely exists, it is clear from population statistics and product chemistry that there is a serious problem.  (Note that when population statistics and product chemistry show a result that the ANTZ do not like — say that e-cigarettes work and are low risk — they insist that it is of no value.  But when they like the result they embrace it.  Only politics matters to these people; they just make up scientific methods to further their politics.)

But the problem seems to be largely attributable to the other plant ingredients and a caustic chemical that are present (see this post for details), so the lie is not that the dip used by Indians and their neighbors is bad for you.  The lie is that it is smokeless tobacco.  Because, of course, we know that the risks from actual smokeless tobacco are so low that they cannot even be shown to exist.  (A few archaic variants perhaps had a risk that was a few percent that of smoking, but modern popular products have a risk so low it is speculative, based on predicting that nicotine has some adverse consequences.)

Suggesting that tobacco is causing these diseases is basically like claiming that tomato slices are fattening:  Tomato slices are typically the third ingredient in a fast-food burger, after the meat (including the grease it is cooked in) and the bun/wheat flour.  Fast food burgers are fattening.  So blame the tomatoes!  They are from a plant that is closely related to tobacco, after all, which means it must be their fault.  So if you are buying something in the gutka family in India be sure to get the kind without tobacco, and if you eat fast food burgers be sure to hold the tomato.  According to the WHO, that will make the products healthy.

Gutka is not smokeless tobacco

by Carl V Phillips

There is a popular oral dip product in India called gutka.  It was recently banned, in one way or another, across much of India, though it appears that this has had relatively little impact (other than perhaps raising the price to the extremely poor people who are most of the users).  Gutka is more popular in that country than is smoking, and is used by an absolutely enormous number of people.

Gutka, and the somewhat similar paan that is popular in Pakistan, appears to pose a very serious risk for oral cancer and other oral diseases, and perhaps other serious diseases.  The health consequences appear comparable to those from smoking, and might even be worse — in particular because, unlike with smoking, many of the serious effects appear to occur before old age.  (The “appear” caveats I keep repeating reflect the fact that most of the epidemiology about these products is so utterly lousy that precision is impossible — we had better quality information about smoking half a century ago.  But there is enough information that it is difficult to doubt that there are serious and high risks.)

So, gutka and paan are, indeed, nasty.  But what they are not — contrary to the typical portrayal — is tobacco.  Gutka does contain tobacco, and paan sometimes does (but not always), but it is not the first ingredient and may not even be the second.  The first ingredient in gutka is areca nut (also known as betel nut), and other ingredients include catechu (a derivative of the acacia tree), various flavorings, and calcium hydroxide (aka slaked lime, or just lime).  The ingredients in the one packet of it that I have that lists the ingredients (most do not) are “betelnuts, tobacco, catechu, cardamom, lime, menthol, natural & artificial flavors”.

So this is tobacco only in the sense that a Big Mac, fries, and Coke is lean beef, potatoes, and water.  The latter are major components of those products, of course. If they were all that was consumed it would not exactly be healthy eating, but they are not all that bad for you.  But a funny thing happens when you consider everything in the foods (various unhealthy fats, high glycemic carbohydrates, carcinogenic products from cooking, etc.) — the meal becomes rather unhealthy.  This is a nearly perfect analogy to the deadly implications of calling gutka “tobacco”.

Something in gutka is pretty clearly quite unhealthy.  Lime is a good candidate — it is quite caustic on your skin, as you might have experienced, and is even worse for your oral mucosa.  It has fairly obvious and rapid negative effects.  But it might be that holding areca nut or catechu in your mouth for a long time is quite harmful too.  The one thing that we can be pretty sure is not causing most of the harm is tobacco.  Why?  Because it is the one of the ingredients that has been extensively studied, as an oral dip exposure, and has been found to produce minimal risk.

To be precise and careful (quite unlike most of those who write about this topic), it is possible that the interaction of tobacco with the other ingredients causes more harm than the other ingredients would cause if the tobacco were absent.  It is also possible that because of the way this particular tobacco is processed, it causes harms that American and Swedish style smokeless tobacco do not.  (There is a plausible but unsubstantiated hypothesis that the much higher concentrations of nitrosamines in some non-Western and archaic products could make them much more hazardous, though there is no evidence that it would be anywhere close to as bad as gutka is.)  Thus, we cannot conclude that the role of the tobacco is benign, but it is clearly wrong to suggest it is the main source of the problem.

Who suggests that?  Pretty much everyone.  The impetus for me writing this post was running across this newspaper story about how the gutka ban is failing due to the black market, with a headline that refers to it as “chewing tobacco”.  But it is not just bad reporters and casual observers who make the mistake.  The packets of gutka I have all display the mandated statements “tobacco kills” and “tobacco causes cancer” and what I assume are their Hindi equivalents.  I do not know whether current products still have those statements (once you ban something, it is difficult to enforce labeling regulations, after all), but the point is that the government’s official statements describe the product as “tobacco”.  This is probably the fault of the World Health Organization, since India’s policy is pretty much “do whatever WHO tells us to do”, but I actually do not know the story.  (Anyone know?  Please let me know.)

But it gets even worse than that.  The anti-THR liars have made a concerted effort to trick Westerners into believing that the apparent harms from Indian “tobacco” are relevant to Western products.  The classic example of this IARC Monograph 89, from the International Agency for Research on Cancer — a unit of WHO that primary is known for its science-by-committee declarations, and is mistakenly seen to be an authoritative and apolitical research organization.  The authors of that document — including longtime professional anti-THR activists like Stephen Hecht (already represented in this blog), Scott Tomar (who got a passing mention but seems to have disappeared), and Deborah Winn (who will likely make an appearance) — tried to bury the fact in their 626 pages that their conclusion that smokeless “tobacco” causes cancer was basically based just on studies of gutka and paan along with a single old study of an archaic American product.

I realize that this post leaves the reader with many points of curiosity that call for more information.  I will try to circle back to these sometime.  But I will conclude by creating one more:

Why did I say it was deadly to refer to gutka as tobacco?  THR in the West is about replacing smoking with smoke-free alternatives.  But in South Asia, there is a lot of room for something else that could be called THR:  The replacement of gutka and paan with smokeless tobacco (snus).  Western-style smokeless tobacco could be made domestically (and thus be affordable, though perhaps more expensive than the current products — I am not sure) and it would presumably have about the same unmeasurably low risk as snus.  Given that the impact of the local dip products is similar to that from smoking, this has similar potential to Western THR.  But — as with Westerners who think that “tobacco” or nicotine is the problem rather than smoking — this is very unlikely to be pursued so long as everyone thinks that it is the tobacco that is the problem.

See also: WHO lying about smokeless tobacco again and The biggest victims of WHO’s anti-harm-reduction efforts are in India